Rosen & Barkin's 5-Minute Emergency Medicine Consult (317 page)

• Pain in the cranium, orbits, or upper neck
  
• Pain within the skull is projected to the surface:
  
  • Intracranial:
    
    • Arteries, veins, dura, meninges
      
  • Extracranial:
    
    • Skin, scalp, fascia, muscles
      
    • Mucosal linings of the sinuses
      
    • Arteries
      
    • Temporomandibular joints, teeth
      
• Pain is transmitted via the V cranial nerve.
  
• May be caused by a number of mechanisms:
  
  • Nerve irritation
    
  • Traction on pain-sensitive vessels
    
  • Vasodilatation of pain-sensitive vessels
    
    • Hypoxia, hypercapnia, fever, histamine injection, nitroglycerin ingestion
      
• Complaint in 2–4% of all ED visits:
  
  • 95% have a benign etiology (lower in patients older than 50 yr)
    
  • Life-threatening etiologies are rare and can be difficult to diagnose.
    

• Migraine:
  
  • Intra/extracranial vasodilatation and constriction of pain-sensitive blood vessels
    
  • May also involve cortical depression
    
  • Throbbing headache
    
• Tension:
  
  • Requires ≥10 attacks of a similar nature
    
  • Unknown etiology (possibly serotonin imbalance, decreased endorphins, spasm)
    
  • Most common type of recurring headache
    
  • Triggered by poor posture, stress, anxiety, depression, cervical osteoarthritis
    
  • Bilateral, nonpulsatile, band like
    
  • Mild to moderate intensity
    
  • 4–13 hr duration
    
• Cluster headaches:
  
  • Triggered by alcohol, certain foods, altered sleep habits, strong emotions
    
  • May involve vasospasm near cranial nerves
    
• Intracranial (traction, pressure):
  
  • Mass lesions
    
  • Idiopathic intracranial hypertension
    
• Extracranial (compression):
  
  • Pathology causing pain in a peripheral nerve of the head and neck
    
• Inflammation:
  
  • Temporal arteritis
    
  • Cerebral vasculitis
    
• Thrombosis:
  
  • Cerebral venous sinus thrombosis (CVST)
    
• Impaired vascular autoregulation/endothelial dysfunction:
  
  • Posterior reversible leukoencephalopathy syndrome (PRES)
    
  • Reversible cerebral vasoconstriction syndrome (RCVS)
    

Serious causes of headache in children are rare but those who come to the ED for this complaint should all have follow-up with a pediatrician.

Older patients with new headache have a higher likelihood of a serious etiology and should have more thorough evaluation with a low threshold for imaging.

In addition to all other causes of headache, pregnant women (and recently postpartum women) are at increased risk for CVST, eclampsia, PRES, and RCVS.

DIAGNOSIS

• Attributes of the pain—PQRST:
  
  • Provocative and palliative features:
    
    • Position of the head, coughing or straining (increase suggests elevated ICP), and movement
      
  • Quality:
    
    • Throbbing or continuous
      
    • Deep or superficial
      
    • Change compared to prior headaches
      
  • Region
    
  • Severity
    
  • Worst headache of life?
    
  • Timing
    
  • Sudden or gradual?
    
• Associated findings:
  
  • Visual symptoms, dizziness, nausea, vomiting
    
• Historical factors indicating additional testing:
  
  • New onset:
    
    • Age >50
      
    • HIV, transplant, or cancer patient?
      
  • Trauma or falls (even without headstrike)
    
  • Persistent vomiting
    
  • Any new focal neurologic or visual symptoms
    
• Risk factors for cerebral sinus thrombosis:
  
  • Malignancy
    
  • Pregnancy (or postpartum)
    
  • Protein S or protein C deficiency
    
  • Oral contraceptive
    
  • Ulcerative colitis
    
  • Behcçet syndrome
    

• Complete neuro exam including cranial nerves, motor, sensation, deep tendon reflexes, gait
  
• Examine for papilledema.
  
• Evaluate skin for rashes:
  
  • Zoster
    
  • Purpura
    
• Palpate temporal arteries
  

• Detailed history, CNS, HEENT, and neck exam
  
• Factors indicating testing beyond the history and physical exam:
  
  • Severely elevated diastolic BP
    
  • Fever
    
  • Altered level of consciousness
    
  • Papilledema
    
  • Abnormal neurologic exam or meningismus
    

• CSF:
  
  • Essential in suspected meningitis, subarachnoid hemorrhage (SAH)
    
• ESR:
  
  • If temporal arteritis or other inflammatory disorders suspected:
    
    • See Giant Cell Arteritis
      

• Head CT scan:
  
  • Indications:
    
    • Uncertain diagnosis based on history and physical exam (leaving open the possibility of serious causes)
      
    • Signs of increased ICP
      
    • “First or worst” headache
      
    • Abrupt onset
      
    • New focal neurologic abnormalities
      
    • Papilledema
      
    • Recurrent morning headache
      
    • Persistent vomiting
      
    • Associated with fever, rash, and nausea
      
    • Trauma with loss of consciousness, focal deficits, or lethargy
      
    • Altered mental status, meningismus
      
  • Definitive test for SAH if performed within 6 hr of onset and read by an attending radiologist
    
  • Within 24 hr, >95% sensitive (sensitivity falls rapidly with time and is 50% at 7 days out)
    
• Sinus imaging may show acute sinusitis; chronic sinusitis rarely causes acute headache.
  
• MRI:
  
  • Indicated to assess for etiologies that are missed by CT scan and LP:
    
    • Posterior fossa lesion
      
    • Pituitary apoplexy
      
    • CVST
      
• MRA:
  
  • Indicated if SAH suspected, CT is negative, and unable to perform lumbar puncture
    
  • Suspicion of carotid or vertebral dissection (e.g., recent neck manipulation or trauma)
    
  • Nonmigrainous vascular cause suspected (e.g., RCVS)
    

Lumbar puncture:

• Perform CT 1st if:
  
  • New focal neurologic finding
    
  • Papilledema
    
  • Abnormal mental status
    
  • HIV positive or immunosuppressed
    
• Detect intracranial and meningeal infections
  
• Detect blood not evident on CT scan:
  
  • There is no specific threshold number of red cells below which SAH is excluded – the RBC count is a function of time from onset.
    
• Opening pressure:
  
  • Essential to diagnose pseudotumor cerebri and CVST
    
  • Can distinguish traumatic tap vs. true hemorrhage.
    
• Xanthochromia:
  
  • Should be visible by 12 hr after onset of a SAH
    
  • Visual inspection is the most commonly used method – spectrometry (is more sensitive but has a high false-positive rate).
    

• Note: There can be significant overlap in these groupings.
  
• Acute single headache:
  
  • SAH
    
  • Meningitis
    
  • Vascular:
    
    • Acute intracerebral hemorrhage
      
    • Hypertensive encephalopathy
      
    • Cranial artery dissection
      
    • CVST
      
    • Cerebellar stroke
      
  • Ocular:
    
    • Acute narrow-angle glaucoma
      
    • Pituitary apoplexy
      
    • Temporal neuritis
      
  • Traumatic
    
  • Acute sinusitis
    
  • Toxic/metabolic:
    
    • Fever
      
    • Hypoglycemia
      
    • High-altitude disease
      
    • Carbon monoxide poisoning
      
  • Narcotic, alcohol, or benzodiazepine withdrawal
    
  • Post lumbar puncture
    
  • Cold stimulus headache
    
• Acute recurrent headache:
  
  • Presenting within days to weeks of onset
    
  • CVST
    
  • Pseudotumor cerebri
    
  • Temporal arteritis
    
  • SAH (rebleed)
    
  • Migraine, cluster, tension
    
  • Hypoxic
    
  • Trigeminal neuralgia
    
  • Postherpetic neuralgia
    
  • Coital and exertional headache
    
• Subacute headache:
  
  • Within weeks to months of onset
    
  • Chronic subdural hematoma
    
  • Brain tumor
    
  • Brain abscess
    
  • Chronic sinusitis
    
  • Temporomandibular joint syndrome
    
  • Chronic post-traumatic headache
    
  • Pseudotumor cerebri (idiopathic intracranial HTN)
    
  • Temporal arteritis
    
• Chronic headache:
  
  • Months to years since onset
    
  • Chronic tension headache
    
  • Analgesic abuse/rebound
    
  • Depression
    
  • Extracranial:
    
    • Trigeminal neuralgia: Transient, shock like facial pain
      
    • Temporal arteritis: Elderly, severe, scalp artery tenderness/swelling
      
    • Metabolic: Severe anemia
      
    • Acute glaucoma: Nausea, eye pain, conjunctival injection, increased IOP
      
    • Cervical: Spondylosis, trauma, arthritis
      

TREATMENT

• ABCs if altered mental status
  
• Empiric antibiotics if bacterial meningitis is suspected, acyclovir if immunocompromised
  

• Migraine (See Headache, Migraine)
  
• Tension:
  
  • Aspirin
    
  • Acetaminophen
    
  • NSAID
    
  • Nonpharmacologic (meditation, massage, biofeedback)
    
• Cluster (See Headache, Cluster)
  
• Temporal arteritis (See Giant Cell Arteritis)
  
• Intracranial infection (See Meningitis)
  
• Intracranial hemorrhage (See Subarachnoid Hemorrhage)